HOMESTAY APPLICATION FORM

Applicant Details

Please complete all details in block letters, sign and return to the above email address.

How do you know us?(Required)

Applicant Name(Required)

First Last

Name of person completing this form

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Enter Email Confirm Email

I give permission to Shafston international College to share my email address to other homestay for car pooling purposes(Required)

Mobile Phone Number(Required)

Work Phone Number

Home Phone Number

Do you host students from any other organisation?(Required)

If Yes, please list the name of organisations(Required)

How long have you been a host family?(Required)

Residents Details

How many people residing in your place?(Required)

Please list all persons including yourself, residing in your house during the next 12 month period. Please include any immediate family member who may stay in your home. Complete all details below.

Family Member 1

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 2

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 3

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 4

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 5

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 6

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Family Member 7

Full Name(Required)

First Last

Relationship(Required)

Gender(Required)

Occupation(Required)

Date of Birth(Required)

Other Family Members(Required)

Full Name

Relationship

Gender

Occupation

DoB

If you have 8 or more family members, please list their information here

Family Description

Main Language of Household(Required)

Other Language in Household

Does Any family member smoke?(Required)

Is Smoking allowed:(Required)

Outside

Inside

No Smoking Allowed

Do you have pets?(Required)

If yes, please specify the pet information:(Required)

Name

Breed

Vaccinations

Outdoor/indoor

Character

Please describe the breed, name, vaccinations, outdoor/indoor status and character.

Blue Card Info

Do you and your family members have A Blue Card?(Required)

If yes, please specify details: (Required)

Full Name

Blue Card Registration Number

Expiry Date

Facilities & Neighbourhood Description

Please give details of the public transport facilities available to your student.(Required)

How many rooms do you have available for students?

SINGLE ROOMS(Required)

(i.e one bed)

TWIN ROOMS(Required)

(i.e two beds)

Please list the number of the following facilities you have at home that are available for students:

BATH(Required)

SHOWER(Required)

TOILET(Required)

LAUNDRY FACILITIES(Required)

COMPUTER(Required)

INTERNET ACCESS(Required)

TELEVISION(Required)

VIDEO/DVD/RADIO(Required)

PIANO(Required)

SWIMMING POOL(Required)

GARDEN(Required)

OTHER

Are there any evenings when cooked meals cannot be provided?(Required)

If yes, please specify which evenings:(Required)

Do you provide microwave meals?(Required)

If yes, please specify how often:(Required)

Health & Safety

Ever been arrested or convicted of any criminal offence, other than a traffic violation?(Required)

If yes, please explain. If not, please write N/A

Have a history of drug or alcohol abuse?(Required)

If yes, please explain. If not, please write N/A

Have a chronic illness, disability or any physical, mental or emotional problems?(Required)

If yes, please explain. If not, please write N/A

Brief Description

When we send confirmation of homestay to the students we like to include a brief description of the host family. A student may feel nervous about their trip and sharing some additional information makes them feel confident about where they are going and assures them of the warm welcome waiting for them.

Example: Mark and Jenny Smith live in Paddington in the eastern Suburbs of Brisbane, close to many local shops. The Smith’s live in a 4 bedroom home in a quiet street. Their home is very close to public transport, bus NO. 322 goes every 15 minutes and goes past Shafston College. Jenny is a teacher and in her spare time enjoys travelling and gardening. Mark is an architect and enjoys writing and golf. They have 2 children, Margo and Will who are twins and attend the local primary school. The Smith family look forward to welcoming you into their home

Your Brief Description(Required)

Please include as much detail as possible.

Notes

The information that you enter on this form is privileged and is kept in accordance with the Privacy Act. Under this federal Legislation you are entitled to access any records held on you. For more information on the Privacy Act, please visit – www.privacy.gov.au

Full Name(Required)

Signature(Required)

Date(Required)

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